Are accident and emergency attendances increasing?

Pressures on accident and emergency (A&E) departments hit the headlines last week, with the Prime Minister and Leader of the Opposition trading statistics across the despatch box at Prime Minister’s Question Time. But what are the facts about A&E attendances?

Figure 1 shows trends in attendances in English NHS A&E units over the past 26 years. The topline trend shows that for 15 years – from 1987/8 to 2002/3 – attendances were essentially unchanged at around 14 million per year. But in 2003/4 they jumped – by nearly 18 per cent – to 16.5 million, and rose to 21.7 million by 2012/13. This is an overall rise of around 7.5 million (a 50 per cent increase) over the past decade.

Figure 1: Annual attendances in English A&E units: 1987/8 to 2012/13

Data source: Department of Health, Total time spent in accident and emergency (pre-2011/12 Q2) and NHS England, A&E waiting times and activity (current)

While the Secretary of State for Health, Jeremy Hunt, has suggested that changes to the GP contract around 2004 are to blame for the rise in A&E activity, the facts about accident and emergency workload statistics are not straightforward.

As Figure 1 also shows, in 2003/4 – when the large increase in attendances started – there was a change in the data series. Until 2003/4, statistics on A&E attendances included ‘major’ A&E units only. But around this time more, smaller units – including walk-in centres (WiCs) and minor injuries units (MIUs) – were introduced with the intention of diverting less serious emergency cases away from the larger, more expensive A&E departments, and the statistical collection was changed to record attendances separately for ‘type 1, 2 and 3’ units. Type 1 essentially reflecting major A&E units and types 2 and 3 defined as the smaller, walk-in and minor injuries units, together with specialist emergency departments.

So, much of the increase in 2003/4 was due to previously unrecorded attendances now being collected, but also additional – but less serious – work being carried out in the new units. From 2003/4 to 2012/13, attendances in type 1 units have remained more or less unchanged. It is attendances in type 2 and 3 units that account for all the increase.

While the NHS has experienced a phenomenal increase in accident and emergency workload over the past decade, over the past 30 months this increase has started to level off. Figure 2, for example, shows weekly attendances between November 2010 and April 2013 together with a trend line. The trend increase over the whole period is around 3.5 per cent – about 1.3 per cent per year.

Figure 2: Weekly attendances in A&E units: November 2010 to April 2013

Data source: NHS England, Weekly SitReps, 2013-14

Over the past decade there has certainly been a huge increase in work. But this is partly attributable to the changes in statistical collection and a degree of ‘supply induced demand’ as new routes into emergency care (WiCs, MIUs) opened. In addition, the possible substitution of some types of care (a visit to the GP) by others (a visit to a minor injuries unit) may have increased A&E attendance statistics, but given that WiCs and MIUs are generally not open out-of-hours, it is not easy to see how the rising workload of these services is linked to changes in GP out-of-hours arrangements, as implied by the Secretary of State for Health.

The increase in A&E workload has slowed in recent years, so the question now is not so much how to slow the speed of the increase, but how close to capacity the system is. The recent figures showing that the target that 95 per cent of patients should not wait longer than four hours in A&E is being breached on an increasingly regular basis is indicative of capacity problems amongst other things. Slowly raising the temperature does eventually boil the frog.